• 제목/요약/키워드: Patient care report

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Completeness of Patient Care Report (PCR) by Paramedics

  • Lee, HyoJu;Kim, JongHo;Yun, Seong Woo
    • Journal of information and communication convergence engineering
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    • 제20권3호
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    • pp.204-211
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    • 2022
  • This study evaluated the completeness of patient care report (PCR). A retrospective quality analysis was conducted using raw data of 122,140 EMS activity reports prepared by paramedics in Gyeonggi-do from April 1 to May 31, 2021. In all, 67,830 cases of normal transfers were statistically analyzed using IBM SPSS Statistics version 22, and statistical significance was set at p<0.5. The 119EMT_2 certificate was omitted in 50,037 (73.8%) cases, followed by time-related items in 1,227 (1.8%) cases. In the primary assessment of vital signs, systolic blood pressure was omitted and erroneous in 1,218 (1.9%) and 1,129 (1.8%) cases, respectively. In the secondary assessment, the completeness of all vital sign items was approximately 70%. Advanced emergency care and online medical control (OLMC) reporting showed discrepancies in all items. As the severity of the patient's condition increased, the errors in the Patient care report (PCR) also increased, at a significant level (p= .00). Paramedics must be aware of the importance of completing the activity report.

CARE 지침에 따른 대한한의학회지의 증례보고에 대한 질 평가 (Evaluation of the Quality of Case Reports from the Journal of Korean Medicine Based on the CARE Guidelines)

  • 최성열
    • 대한한의학회지
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    • 제41권2호
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    • pp.122-136
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    • 2020
  • Objectives: A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. The purpose of this study is to evaluate the quality of case reports from the Journal of Korean Medicine by the CARE (CAse REport) Guideline. Methods: Case reports published in the Journal of Korean Medicine from January 2016 to March 2020 were searched from Oriental Medicine Advanced Searching Integrated System (OASIS). We assessed the quality of reporting based on CARE (CAse REport) guideline as 'Sufficient', 'Not-Sufficient' and 'Not-Report'. Results: A total of 22 case reports were finally included for the assessment. The reporting items were reported as of reporting quality. After checking the result, there was a deviation in the sub-item reporting rate by a maximum 89.29%, a minimum 66.67% and a median 82.14% in case reports. Also after checking the quality in case reports by 28 detailed items in CARE guidelines, there were not reported 77% or more in the 5 sub-items 'Intervention adherence and tolerability', 'Informed consent', 'Adverse and unanticipated events', 'Diagnostic challenges', 'Patient perspective'. Conclusion: There is a need to improve the quality of case reports in the journal of Korean Medicine based on various studies using CARE guideline.

경추성 현훈 환자의 복합 한의진료 경과 및 삶의 질 변화 : CARE 가이드라인에 따른 증례보고 (Herbal Medicine and Local Acupuncture Point Stimulation Administration and Their Clinical Effect on Quality of Life for Cervicogenic Dizziness (CGD) Patient: A CARE Guideline Compliant Case Report)

  • 김은미;조희근
    • 대한한방내과학회지
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    • 제41권3호
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    • pp.414-423
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    • 2020
  • Background: This study examines the clinical effect on quality of life of herbal medicine and local acupuncture point stimulation administration for a cervicogenic dizziness (CGD) patient. This case report was described in accordance with CARE guidelines. Case Report: A 25 year-old female patient suspected to be suffering from CGD was examined. The patient was treated with herbal medicine and local acupuncture point stimulation. We used the Headache Impact Test-6 (HIT-6), Dizziness Handicap Inventory (DHI), Pittsburgh Sleep Quality Index (PSQI), 36-Item Short Form Health Survey Version 2 (SF-36v2), and verbal numerical rating scale (VNRS) to assess the patient's symptoms. As new herbal medicine and local acupuncture point stimulation were applied, dizziness, headache, and neck pain symptoms improved. Quality of life affected by the symptoms significantly improved. Adverse effects were not observed. Conclusions: This study may suggest that herbal medicine and local acupuncture point stimulation may be effective therapy for the treatment of typical symptoms in patients with CGD.

당뇨병성 하지궤양을 가진 농촌 노인의 상처간호 사례보고 (Wound Care in an Older Rural Patient With Diabetic Lower Extremity Ulcers: A Case Report)

  • 신은지;박경희;이경희
    • 한국농촌간호학회지
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    • 제18권2호
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    • pp.92-98
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    • 2023
  • Purpose: This study describes a case report of wound care performed by a community health practitioner for a rural older adult with diabetic ulcers. Methods: Data were collected from a rural older adult who had a diabetic lower extremity ulcer, and wound dressing was applied over 20 weeks after the skin graft operation. Results: The patient visited a primary healthcare post for regular ulcer care, and a community health practitioner applied appropriate wound dressings and managed the patient's diabetic condition. Conclusion: In rural areas, where healthcare resources are scarce compared with urban areas, rural nurses, such as community health practitioners, are primarily required to manage rural residents' health problems. Advanced nursing practices such as complicated wound care should also be appropriately provided to patients by enhancing rural nurses' competencies in the changing health care environment.

외래 환자경험에 영향을 주는 요인 (Factors Affecting Patient Experience with Outpatient Care)

  • 김경훈
    • 보건행정학회지
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    • 제31권2호
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    • pp.207-216
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    • 2021
  • Background: Good patient experience is positively associated with adherence to treatment recommendations, better clinical effectiveness, and health outcomes. This study aims to find out the key factors affecting positive patient experience to improve the quality of care using nationally representative survey data. Methods: The data was collected from the 6th National Health Nutrition Survey in 2015. Four patient experience items were investigated for patients with visiting outpatient care over the past year. Positive patient experience was defined as a case of responding always or usually yes. The t-test, chi-square test, and multiple logistic regression were performed to determine the key factors affecting the outpatient experience. Results: More than 80% of the respondents reported their care experience as positive excluding doctor spending enough time during the consultation. Male, poor health status, and single/divorced, and the longer time interval between outpatient care visit and survey were found to be significantly correlated with negative care experiences in the multiple logistic regression. Patients who received outpatient care at the oriental medicine clinic had a positive experience compared to those received outpatient care at the general hospital. However, patient factors including age, income, job, and insurance type had no significant association with patient experience. Conclusion: Health care providers should prioritize patients who report negative patient experiences and implement management decisions to improve the patient experience.

병원중심 가정간호 기관의 기록체계개발 - 미국 일개 종합병원을 대상으로 - (Development of Documentation System in Hospital-based Home Health - in one general hospital in the U.S.A. -)

  • 강창희
    • 한국보건간호학회지
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    • 제6권2호
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    • pp.58-69
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    • 1992
  • The purposes of this study were 1) to assess the currunt documentation system 2) to identify the problems in communication regarding to documentation 3) to develop new documentation system 4) to suggest effective communication channel using new documentation system Research was conducted by direct observation, chart review, staffs interview and servey. Results were as follows: 1) nursing care plans were not used in ongoing care 2) documentation format was primarily narrative and charting was time consuming 3) documentation did not reflect the nursing process 4) patient records were not used as effective communication tool between case manager and part time nurse 5) difficult access to patient record for nurse manager created inefficiency in coordinating 6) documentation of patient education did not describe the precise contents of education, and the responses of the patients and evaluation To solve these problems, new documentation format was developed. With new formats nurses : 1) use standardized care plan which contains nursing diagnosis, ecpected outcome, time frame for evaluation, flow sheet for updating the plans 2) leave one copy of care plan at patient home for mutual agreement with patent and communication among nursing staffs 3) carry one copy of care plan for updating 4) document and evaluate the patient education using education check list keeping in patient's home 5) document nursing process in focus charting visit report 6) carry one copy of visit report 7) have one copy of visit report which was deligated to part time nurses 8) use documentation in direct communication with part time nurse 9) use beeper and memo to promote communication

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Patient navigation in women's health care for maternal health and noncancerous gynecologic conditions: a scoping review

  • Jiwon Oh
    • 여성건강간호학회지
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    • 제30권1호
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    • pp.26-40
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    • 2024
  • Purpose: This study investigated the scope of patient navigation studies on women's health care for maternal health and noncancerous gynecologic conditions and aimed to report the characteristics of the identified patient navigation programs. Methods: A scoping review was conducted following Arksey and O'Malley's framework. Five electronic databases were searched for relevant studies published in English: PubMed, Embase, Cochrane Library, CINAHL, and PsycInfo. There were no restrictions on the publication date and the search was completed in July 2023. Results: This scoping review included 14 studies, which collectively examined seven patient navigation programs. All selected studies were related to maternal health issues (e.g., perinatal health problems and contraception for birth spacing). Close to two-thirds of the patient navigation services were provided by women (n=9, 64.3%) and half by lay navigators (n=7, 50.0%). The majority incorporated the use of mobile health technologies (n=11, 78.6%). All of the patient navigation programs included in the review coordinated the necessary clinical and social support services to improve women's access to care. Conclusion: Patient navigation appears to be in its nascent phase in the field of maternal health. The results of this study suggest that the implementation of patient navigation services could potentially improve access to care for socially disadvantaged women and families. Furthermore, providing patient navigation services that are specifically tailored to meet women's needs could improve the quality of maternity care.

Early Hospice Consultation Team Engagement for Cancer Pain Relief: A Case Report

  • Jisoo Jeong
    • Journal of Hospice and Palliative Care
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    • 제27권2호
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    • pp.77-81
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    • 2024
  • This case report explores the challenges and complexities associated with opioid management of cancer pain, emphasizing the importance of early involvement of a hospice consultation team and the adoption of a multidisciplinary approach to care. A 56-year-old man with advanced pancreatic cancer experienced escalating pain and inappropriate opioid prescriptions, highlighting the shortcomings of traditional pain management approaches. Despite procedural intervention by the attending physician and increased opioid dosages, the patient's condition deteriorated. Subsequently, the involvement of a hospice consultation team, in conjunction with collaborative psychiatric care, led to an overall improvement. The case underscores the necessity of early hospice engagement, psychosocial assessments, and collaborative approaches in the optimization of patient-centered palliative care.

병원의 급성심근경색증 진료 결과 공개의 효과 (Impact of public releasing of hospitals' performance on acute myocardial infarction outcomes)

  • 은상준;김윤;이은정;장원모
    • 한국의료질향상학회지
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    • 제17권1호
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    • pp.69-78
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    • 2011
  • Objectives : The purpose of this study was to determine whether the published AMI report card could reduce in-patient mortality, 7-day after discharge mortality, and length of stay (LOS). Methods : Interrupted time-series intervention analysis was used to evaluate the impact of the report card for AMI care quality in November 2005 in terms of risk-adjusted in-patient mortality, risk-adjusted 7-day after discharge mortality, and DRGs case-mix LOS using the claim data of Health Insurance Review and Assessment Service. Results : Public disclosure of AMI care quality decreased risk-adjusted in-patient mortality and DRGs case-mix LOS by 0.00050% per month and 0.042 days per month respectively, however there was no effect on risk-adjusted 7-day after discharge mortality. Patterns of effect of public disclosure on AMI outcomes were a fluctuating pattern on risk-adjusted mortalities and a pulse impact for 1 month on DRGs case-mix LOS. Conclusions : We found the public disclosure of AMI care quality had decreasing effects on risk-adjusted in-patient mortality and DRGs case-mix LOS, but the size of the effect was marginal.

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다차원 시각화 방법을 이용한 데이터베이스 접근방법 (Visualized Multi-Dimension Access to Database)

  • 백우진;좌대훈;김법용
    • 한국정보관리학회:학술대회논문집
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    • 한국정보관리학회 2006년도 제13회 학술대회 논문집
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    • pp.191-196
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    • 2006
  • Traditionally, nurses keep the written patient records, which are referred as nursing care plan. Nursing care plan reports are one of the most important documents in the application of nursing processes. Typically, nurses prepare the plans by including general patient information as well as the patient's medical history information. In addition, the patient's developmental history and other specific health related information are part of the plans. The plans are usually concluded with the goals of the nursing care plan, nursing diagnoses, expected outcomes of the care, and possible nursing interventions. The nursing diagnoses, outcomes, and interventions are defined by North American Nursing Diagnosis Association (NANDA). This means that the nurses will select the appropriate diagnoses, outcomes, and interventions from an approved set. We developed a web-based nursing care plan generation system. In this paper, we report our work on developing a visual interface to the NANDA nursing diagnoses, outcomes, and interventions database as a part of the web-based nursing care plan generation system.

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